March 2016

You have anaesthetised a 5-year-old boy for manipulation of a forearm fracture. During the operation you notice that he has multiple bruises on his upper arms and body that you think may indicate child abuse.
  • a)  Which other types of physical injury should raise concerns of abuse in a child of this age? (6 marks)
  • b)  What timely actions must be taken as a result of your concerns? (7 marks)
  • c)  List parental factors (5 marks) and features of a child’s past medical history (2 marks) that are known to increase the risk of child abuse.
Child protection issues of relevance to the anaesthetist Pass rate 44.7% This is an important topic which is relevant to the practice of paediatric anaesthesia and forms part of mandatory training for all doctors. The question was not particularly well answered with many candidates appearing not to have knowledge of the presenting signs and symptoms of child abuse. Candidates assumed that the parents were harming their child so missed important steps such as informing the senior paediatrician before contacting social services. The general lack of knowledge on this subject was reflected in the poor pass rate.
September 2015
You are called to the Emergency Department to see a 2 year-old child who presents with a 4-hour history of high temperature and drowsiness. On examination there is prolonged capillary refill time and a non- blanching rash. A presumptive diagnosis of meningococcal septicaemia is made.
  • a)  What are the normal weight, pulse rate, mean arterial blood pressure and capillary refill time for a child
    of this age? (4 marks)
  • b)  Define appropriate resuscitation goals for this child (2 marks) and outline the management in the first
    15 minutes after presentation. (7 marks)
  • c)  After 15 minutes, the child remains shocked and is unresponsive to fluid. What is the most likely pathophysiological derangement in this child’s circulation (2 marks) and what are the important further treatment options? (5 marks)
Paediatric meningitis Pass rate 56.9% The pass rate for this question was the second highest in the paper but the examiners still felt that it was not particularly well answered. Many candidates lost marks because they wrote similar answers for parts (b) and (c), despite the fact that in part (c) they were asked to comment on what they would do if the measures used in (b) were not successful in resuscitating the child. Incorrect dosages of drugs, particularly antibiotics were often quoted.
March 2015
A 5 year-old boy with Autistic Spectrum Disorder (ASD) is listed for dental extractions as a day case.
  • a)  What constitutes ASD (1 mark) and what are the key clinical features? (6 marks)
  • b)  List the important issues when providing anaesthesia for dental extractions in children. (6 marks)
  • c)  Give the specific problems of providing anaesthesia for children with ASD and outline possible solutions. (7 marks)
  • Autistic Spectrum Disorder
    Pass Rate 46.2%, 22.1% of candidates received a poor fail
    It was anticipated that candidates would find this subject matter to be difficult and this was borne out by the pass and poor fail rates. Autistic Spectrum Disorder (ASD) is an important issue within paediatric anaesthetic practice, and this result suggests specific teaching on the topic needs to be undertaken in all Schools of Anaesthesia. Failure to read section (b) correctly led to low scores as candidates did not realise that the question referred to all children not just individuals with ASD.
September 2014
A 5 year-old child presenting for day case dental surgery under general anaesthesia is found to have a heart murmur that has not been documented previously.
  • a)  What features of the history (5 marks) and examination (5 marks) might suggest that the child has a significant congenital heart disease (CHD)?
  • b)  If the murmur is caused by an atrial septal defect (ASD) what ECG findings would you expect? (2 marks)
  • c)  Which imaging modalities might be used in the assessment of the ASD (2 marks) and what specific additional
    information may be obtained? (2 marks)
  • d)  List the current national guidelines regarding prophylaxis against infective endocarditis in children with CHD
    undergoing dental procedures. (4 marks)
  • Pass Rate 39.1%
  • This question was poorly answered by many candidates who could not list the history and examination findings in such a patient. Many felt that congenital heart disease only caused left sided cardiac abnormalities and were ignorant of national guidelines on infective endocarditis prophylaxis although the need for the latter must be encountered on a regular basis in adult subjects.
March 2014

A 5-year-old patient presents for a myringotomy and grommet insertion as a day case. During your pre-operative assessment you notice that the patient has a nasal discharge.

a) Why would it be inappropriate to cancel the operation on the basis of this information alone? (25%)

b) List the features in the history (35%) & examination (25%) that might cause you to postpone the operation due to an
increased risk of airway complications in this patient.

c) What social factors would preclude this child’s treatment as a day case? (15%)
Pass Rate 44.7%

This question was answered poorly considering the issue is “meat and drink” to paediatric day case practice. The majority of candidates did not mention; emotional aspects, financial losses, parental work absence, school absence and inefficient use of hospital resources in the answer. The history section was poorly answered although examination features were more typically known. Surprisingly, social factors were infrequently given although these have a major impact on suitability as a daycase. Overall, there seem to be few candidates thinking about the organisational and logistical aspects of bringing a child in for daycase surgery.
September 2013

a) List the normal anatomical features of young children (< 3 years old) which may adversely affect upper airway management. (35%)

b) Which airway problems may occur due to these anatomical features? (30%)

c) Outline how these problems are overcome in clinical practice. (35%)
65.4% pass rate.

This question was a repeat from the May 2007 paper. Each anatomical feature was linked to an airway problem and how they might be overcome in clinical practice. It is quite acceptable to answer a question like this in the form of a table.









Anatomical featureProblemOvercome by
Pliant sub-mental tissueEasy obstruction by digital pressureEnsure fingers applied to bony surfaces
Short tracheaHigh incidence of endobronchial intubationHigh level of awareness, auscultate chest to check




Similarly an “advantages and disadvantages” question can be answered in this way and can avoid repetition of words and therefore save time.
March 2013

An 8-year-old child with severe cerebral palsy is scheduled for an elective femoral osteotomy.

a) Define cerebral palsy? (15%)

b) List the clinical effects of cerebral palsy on the central nervous, gastro-intestinal, respiratory and musculoskeletal systems with their associated anaesthetic implications. (50%)

c) What are the specific issues in managing postoperative pain in this patient? (35%)
36.4% pass rate.

This question was poorly answered. Adult and paediatric patients with cerebral palsy presenting for surgery are not uncommon. Many examinees had little or no knowledge of the definition of cerebral palsy and could not put forward a coherent answered regarding the anaesthetic management. Awake-fibreoptic intubation was an inappropriate method of establishing the airway in this patient and the mention of sexual dysfunction was irrelevant.

A snapshot from the model answer below highlights the level of knowledge that was required.
Focusing on the gastrointestinal system involvement:
Clinical effects
Flexion deformities/spasticity
Scoliosis
Immobility
Low muscle bulk
Anaesthetic relevance
Positioning problems; pressure sores;
difficult IVaccess
Restrictive respiratory pattern
Unable to assess cardiopulmonary reserve
Temperature control difficulties

One mark was available for each pair of answers (maximum 2)
September 2012

A 4-year-old child is admitted to the Emergency Department with suspected meningococcal septicaemia. You are asked to help resuscitate the patient prior to transfer to a tertiary centre.

a) List the clinical features of meningococcal septicaemia. (35%)

b) Outline the initial management of this patient? (45%)

c) Which investigations will guide care? (20%)
Question 5: Paediatrics/management of meningococcal septicaemia.

67.6% pass rate.

This paediatric emergency is commonly encountered both in Secondary and Tertiary centres. Although the question was answered satisfactorily, marks were lost by not calling for help and inappropriate fluid resuscitation. Many candidates failed to communicate with the tertiary centre for advice or to summon the paediatric retrieval team.

This question was a very good discriminator.
September 2011

A 9-year-old child with Down’s syndrome is scheduled for an adenotonsillectomy.
a) List airway/respiratory (30%), cardiovascular (10%) and neurological (10%) features of the syndrome relevant to the anaesthetist.

b) What are the general principles involved in the preoperative (15%), intraoperative (25%) and postoperative (10%) management of this patient with Down's syndrome?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2011

You are asked to assess a 4-year-old child who is scheduled for a strabismus (squint) correction as a day case procedure.

a) List the anaesthetic related issues this case presents. (60%)

b) During surgical traction, the patient suddenly develops a profound sinus bradycardia. How would you
manage this situation? (10%)

c) Describe the key postoperative problems and relevant management strategies. (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2010

A two year-old child presents to the Emergency Department (ED) with sudden onset of fever (38.5°C aural), sore throat, drooling and stridor.

a) What conditions should be considered in the differential diagnosis? (20%)

b) What would be your initial management of this child in the ED? (25%)

c) How would you subsequently manage a deteriorating child? (45%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2010

You are asked to review a 5 year-old child who has undergone a tonsillectomy earlier that day. The child needs to return to theatre for control of bleeding.

a) What are the important considerations in the assessment of this child? (40%)

b) Compare the advantages and disadvantages of intravenous and inhalational induction of anaesthesia in
this patient. (40%)

c) How may the incidence of post-operative nausea and vomiting be reduced in this child? (10%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2010

You are asked to review a 2 year-old child admitted to the Emergency Department with status epilepticus.

a) Define status epilepticus. (10%)

b) Outline your initial management plan to deal with this patient. (50%)

c) List the common causes of status epilepticus in children. (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2009

A 4 year-old (20kg) girl is admitted with acute appendicitis and is scheduled for urgent surgery. She has been vomiting for two days and is pyrexial 38.7 0C. Her pulse rate is 170 beats per minute with a capillary refill time of 4 seconds.

a) Describe the perioperative intravenous fluid management of this case (60%)

b) Outline the metabolic & clinical complications that can occur with inappropriate intravenous crystalloid therapy. (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2008

A 4 year old (20 kg) is admitted with acute appendicitis and is scheduled for urgent surgery. She has been vomiting for 2 days, is pyrexial, has a tachycardia of 170 bpm and prolonged capillary refill.

a) Describe the perioperative fluid management of this case using intravenous crystalloids. (60%)

b) Outline the complications that can occur with inappropriate intravenous crystalloid therapy. (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2008

a) What strategies are available and appropriate to decrease preoperative anxiety in children for day case surgery? (45%)

A 12 year old girl is admitted for prominent ear correction as a day case. She is very anxious and uncooperative when you see her preoperatively. She will not engage with any attempts to calm her down and subsequently refuses to cooperate with anaesthetic induction. However, her mother is insistent that you go ahead with the anaesthetic.

b) How would you proceed in this scenario? Explain your reasoning. (45%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2007

You are asked to see a 2-year-old boy in the Emergency Department who has stridor and a barking cough. He is febrile and is sitting upright with suprasternal and subcostal recessions.

a) What is stridor and what does it indicate? (15%)

b) List the possible causes of stridor in a child of this age, indicating which is the most likely in this case. (35%)

c) Outline your initial management of this child in the Emergency Department. (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2007

a) List the normal anatomical features of young children (< 3 years old) which may adversely affect airway management. (25%)

b) What airway problems may occur due to these anatomical features? (30%)

c) Describe how these problems are overcome in clinical practice. (35%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2006

Regarding caudal anaesthesia in children:
(a) What anatomical features are important to consider when performing the block (caudal) safely? (30%)
(b) What are the contraindications? (20%)
(c) What are the problems and complications?(20%)
(d) What constraints limit the effectiveness of the block and how can they be overcome? (20%)

Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2005

Describe the perioperative fluid and electrolyte management of a 6 month old child presenting in casualty with abdominal distention requiring urgent laparotomy.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2005

Describe the anaesthesia and analgesia considerations in a child presenting for elective day case orchidopexy.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2005

A one day old term neonate has arrived at your regional paediatric intensive care unit. A congenital diaphragmatic hernia has been diagnosed. The baby is already intubated and receiving artificial ventilation.
Outline, with reasons the principles of preoperative management.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2004

You are asked to anaesthetise an 5 year old child (weight 20 kg) for an emergency appendicectomy.
Describe in detail the induction of anaesthesia with special reference to:- Fluid management (20%)
The airway (50%)
Drug management, including doses (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2004

Outline, with reasons, your peri-operative management of an otherwise healthy 4 year old admitted for tonsillectomy.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2003

You are called to the A and E department to review a 4 year old child who requires intubation. She has a clinical diagnosis of meningococcal sepsis. She has reduced consciousness and a petechial rash.
Describe your immediate management.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2003

A 4 year old child who has been knocked unconscious by a blow from a cricket bat arrives at a paediatric neurosurgical centre. After initial appropriate management a CT scan shows an extradural haematoma. There are no other injuries. Discuss the subsequent management.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2002

Describe the anaesthetic management of a penetrating eye injury in a screaming 5 year old child
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2002

A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-four weeks.

List the risk factors and state how these can be minimised.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2001

Outline the early management of a one year old child with 25% burns caused by scalding.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question